Registration | Company Eight Dance

Electronically submit your information below:

Student Name:

Age:

Date of Birth:

Gender:

Parents Name:

Mailing Address:

Home Phone:

Cell Phone:

E-Mail:

Student Medical Conditions / Allergies:

Emergency Contact (Will Always Contact Parent(s) First):

Emergency Contact Phone:

Emergency Contact Relation To Student:

Name of Class, The Day (ex. Saturday), Time (ex. 1:00pm):

Making Payment For:

Amount Paying:

Credit Card Type:

Expiration Date:

Credit Card Number:

Security Code:

Zip Code:

Legal Agreement: By submitting this form, I acknowledge that all information provided is accurate and complete. I authorize the processing of my payment as indicated above. I understand that my personal information will be kept confidential and used only for the purposes of registration and communication.

I agree to the terms above